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LEXINGTON-BOARD OF PUBLIC WORKS
SEWER DIVIStON
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TOWN OF
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Ai'•
~TE NO _
The undersigned applies for the coIl8truction of a particular sewer conneeting No._
Street and hereby agrees to comply with the Rules and Regulations governing the construction and use of Particul&r
Sewers,as now or at any future time establillhed by the Board of Selectmen.
Am't.of Estimate $_
Am't.Paid $_
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A ,"
_Owner
.Sketcb.of Service Here •
Connection made in street.'c Work completed 19 J~:.'!!J1-,.•.
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